Application - Multi-Employer Fiduciary Renewal

Trust Fund Protection Plan

Renewal Application for Fiduciary Liability Insurance

(hereinafter referred to as the “Renewal Application”)

Important Notice: This is a renewal application for a claims made policy. Words and expressions (other than in the headings) printed in bold are defined in the policy. A reference to the insured means each insured. The policy for which this Renewal Application is made, covers only claims first made against the insureds during the renewed policy period or discovery period (if applicable) and reported to Liberty International Underwriters (LIU) as soon as practicable but in no event later than after the end of the renewed policy period or discovery period, if applicable.

This Renewal Application is an addendum to the original Mainform Application and together with all previous Renewal Applications forms part of the renewed policy. Neither the original nor any renewed policy provides for any duty on the part of LIU to defend any claim.

1. Documents Required

To enable us to quote your renewal, please attach the most recent versions of the following documents only if different from those submitted last year:

• Audited Financial Statements of each plan
• Actuarial Valuation / Report, for each pension plan (if applicable)
• Investment Portfolio including statement of investment polices and procedures
• Copy of Trust Fund Mandate / Agreement
• Copy of Third Party Administration Agreement (if applicable)
• Copy of all communications (ie. Newsletters, brochures) to members of the plan during the past 12 months
• Trust Fund Governance – Copy of the Minutes of Meetings of the Board of Trustees during the past 12 months; copies of documents pertaining to the governance of the plan(s), including: (1) education and training, (2) communications / disclosures to members of the plan

2. General Information

a)Parent Plan / Parent Trust Fund:

b)Address:

Telephone / Fax / E-Mail:

c)Contact (Name and Position):

d)Have there been any changes to the number of plans that form a part of the expiring policy?

Yes No(If “Yes”, please provide details on the changes)

e)Policy Period:From: To:

3. Fiduciaries and Administrative Employees

a)In the past twelve months, have there been any changes to the Board of Trustees?

Yes NoIf “Yes”, please provide details.

b)Has any new or existing fiduciary ever been:

i) Accused or found guilty of a breach of trust? Yes No

ii) Accused or found guilty of any criminal act? Yes No

iii) Refused coverage under a Fidelity Bond? Yes No

If “Yes” to any of the above, please explain:

c)How many times did the Board of Trustees meet in the past 12 months?

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Liberty International Underwriters, a Division of the Liberty Mutual Insurance Company

4. External Service Providers

a)Have there been any changes to any of the external service providers in the last 12 months including changes to the Consultant, Third Party Administrator (“TPA”), Auditor, Lawyer, Actuary, Custodian, Corporate Trustee or Investment Manager?

Yes No

If “Yes”, please provide details and answer:

Do all external service providers carry and have they provided proof that they have their own Errors and Omissions and Fidelity insurance coverage?

Yes No If “No”, please provide details

b)How many times was the Investment Manager’s performance reviewed in the last 12 months?

c)Is the applicant requesting that this policy be extended to cover the TPA?

Yes No

If “Yes”,

1. Is there a written agreement with the TPA?

Yes No (if “Yes”, please provide details)

1. Has the plan given up any rights of recovery against the TPA?

Yes No

1. Indicate the Errors and Omissions insurance coverage carried by the TPA. (Provide details and/or attach copy of insurance certificate if available)
2. Has the TPA in the past 5 years had any claims or disputes?

Yes No (if “Yes”, please provide details)

1. Has the TPA had E&O coverage declined or cancelled within the past 5 years?

Yes No (if “Yes”, please provide details)

d)Have there been, in the past 12 months, any amendments or changes to any agreements (investment management, TPA, Trust, etc.)?

Yes No (if “Yes”, please provide copies of the changes)

5. Plan Valuation

a)Please provide the current values for each plan as per the most recent audited financial statements. (Attach separate schedule if required)

Plan / Year / Total Assets / Annual Contributions / Actuarial Surplus or Deficit (if applicable) / # of Participants
(active/retired)

b)Are all pension plans adequately funded as attested to by an Actuary?

Yes No N/A

If there is an actuarial deficit, please outline measures intended to respond (including copies of any documents submitted to regulators and communications sent to members of the plan).

6. Significant Developments

a)If any plan(s) to be insured under this policy is of a “defined benefit” nature, in the last 12 months, has there been any discussions by the trustees (or by management) regarding the removal of surplus funds from the pension plan(s)?

Yes(Please provide details) No Not a Defined Benefit Plan

b)Has Revenue Canada withdrawn or threatened to withdraw the tax exempt status of any plan in the last 12 months?

Yes(Please provide details) No

c)Has any plan filed for exemption from a prohibited transaction in the last 12 months?

Yes(Please provide details) No

d)In the last 12 months, has there been, or is there now under consideration any merger, acquisition, restructuring or consolidation of the plan or any other recent, ongoing or anticipated changes that could impact any plan or its benefits?

Yes(Please provide details) No

e)Has any plan requested or contemplated filing a request for termination or partial wind-up in the last 12 months?

Yes(Please provide details) No

f)Have there been any amendments to any plan(s) that have resulted in or are expected to result in any reduction of benefits in the next 12 months?

Yes(Please provide details) No

g)Do you have and apply a systematic and diligent collection procedure for outstanding delinquent employer contributions?

Yes(Please provide details) No

h)Do all plans conform to the standards of eligibility, participation, vesting, funding and other provisions of the Pension Benefits Standards Act in Canada (and any similar provincial statute) or ERISA in the US?

Yes No N/A If “No”, please provide details

7. Parent Plan as Authorized Representative

The parent plan is authorized to act on behalf of all insureds in connection with matters respecting the policy including the giving and receiving of notices, the payment and return of premiums and the delivery and acceptance of endorsements.

8. Acknowledgment

The undersigned authorized trustee on behalf of all insureds:

• After consultation with the other insureds and the administrator and/or TPA, declares that the statements and disclosures in this Renewal Application are complete and accurate;
• Declares that there are no known facts material to the risk to be insured that have not been disclosed in this Renewal Application;
• Undertakes to provide to LIU immediate notice of any material changes discovered between the date of this Renewal Application and the effective date of the renewal policy;
• Acknowledges that LIU, if it issues the renewal policy, will be doing so in reliance of the completeness and accuracy of the statements and disclosures in this Renewal Application;
• After consultation with the other insureds and the administrator and/or TPA, acknowledges that if a renewal policy is issued, this Renewal Application becomes an addendum to the original Mainform Application and together with all previous Renewal Applications, forms part of the renewed policy; and
• Authorizes LIU to make any investigation and inquiry in connection with this Renewal Application that it deems necessary.
• Acknowledges that any personal information provided in connection with the coverage applied for, including but not limited to the information contained in this Renewal Application, has been collected in accordance with all applicable privacy legislation. The undersigned confirms that all necessary consents have been obtained for the collection, use, and disclosure of such information for the purposes of assessing the Renewal Application for insurance, and if applicable, investigating and settling claims, detecting and preventing fraud, and acting as required or authorized by law.

For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Liberty Mutual Insurance Company’s insurance business in Canada

Signature:Title:Date:

Chairperson of the Board of Trustees or

Print Name:Longest Serving Trustee

9. Applicant’s Explanations, Notes or Comments:

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Liberty International Underwriters, a Division of the Liberty Mutual Insurance Company